Provider Demographics
NPI:1720353642
Name:ORTIZ, SANTOS EFRAIN
Entity Type:Individual
Prefix:MR
First Name:SANTOS
Middle Name:EFRAIN
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4761 PAULINE RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-4575
Mailing Address - Country:US
Mailing Address - Phone:678-531-0618
Mailing Address - Fax:
Practice Address - Street 1:4761 PAULINE RD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-4575
Practice Address - Country:US
Practice Address - Phone:678-531-0618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45-43250393416L0300X, 146M00000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No3416L0300XTransportation ServicesAmbulanceLand Transport
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate